KDFC: ADR Reporting Form
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Patient information
Here goes some personal information about your patient, all these information will be kept secret and used only for statistical information.
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| Patient name or initals
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| Age:
*
| in years
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| Gender
*
| male female
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| Weight
*
| in Kilograms (Kgs. )
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| Hight
*
| in Centimeters (CMs)
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Reporter information
Here goes your information as a reporter so we can contact you if we need further information.
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| Name or initials of the reporter
*
| Doctor or pharmacist or nurse .. etc
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| Email
*
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| Phone Number
| Optional
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| Can we contact you?
*
| Yes, By E.mail Yes, By Phone Yes, By E.mail OR Phone
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Issue details
here we need all the information related to the ADR,Side effects , harmful effect which you exprinced
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| Suspected product BRAND name:
*
| Write the name of the product which you suspect it's the Reason for what you've experinced
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| Suspected product Chemical name:
*
| The name will be mentioned on the pack as an active ingredient
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| Reason for taking the drug:
*
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| Dose/Route/Frequency of taking the drug:
*
| example: 500 mg/ Oral / twice daily
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| What was the problem the patient experienced after using the product?
*
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| Was the problem solved when you stopped using the product?
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| Yes No I'm still using the product I don't know
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| Did the problem Re appear after introduction of the suspected drug again?
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| Yes No Didn't re use the product I don't know
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Detailed information:
These information are optional but needed to help us to perform a full assessment
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| Specific antagonist used :
| if available
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| Other drugs taken on the same time:
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| Pre- existing medical history :
| Hepatic , cardiac , pregnancy , renal , .. etc
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| More information
| Please provide any more information or comments you wish us to know
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